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ORONO ADMINISTRATIVE OFFICES <br /> I FORMATION DISCLOSURE REQUEST <br /> IIINISESOTA G40V=u4uKNT DATA PRACTICES ACT <br /> REQUESTER NOTE: <br /> A. Requesou <br /> t Frequency - Private Data on individuals. After aningr the <br /> have been supplied the data and informed <br /> uf fo esixf months its ethereafter <br /> data need not be disclosed to You <br /> fOor additional data -on <br /> unless a dispute or action is pending <br /> you has been collected. actual costs in making, <br /> B . You may be required to Pay the copies of information <br /> certifying and/or compiling <br /> requested. <br /> Date of Request: <br /> � c e 4 �u <br /> Requester <br /> Name: <br /> City: - <br /> Address: `� G <br /> Zip <br /> Business: <br /> Home Phone: °/ <br /> Description of Information Rec <br /> ested: <br /> Requester' s Signature: <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY <br /> Handled By: <br /> Department <br /> in DerSOn Mail — <br /> Phone <br /> Request Type= — <br /> Not Subject of Data <br /> Subjec- of Data <br /> Requested By: <br /> Public Private <br /> Information Requested is Classified= <br /> _ <br /> Non-Publicted Non-Public <br /> -rotec <br /> _Confidential — <br /> Bequest is: Approved <br /> Denied Approved in Fart <br /> Remarks/Cents: <br /> Authorized Signature: <br /> x Total Due <br /> Fees: g Rate per Page <br /> No. of Pa es <br />